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Tuesday, January 20, 2015

TREATING IN THE FOURTH DIMENSION

At lunch the other day, a friend asked me about surgical
indications. The discussion turned to
how treatment of kids differed from that in adults with similar problems. I discussed the obvious things, like the
relative size of the child, the anesthesia and other medical concerns, the
relative strength of bones and soft tissues and the presence of growth
plates. But as I talked, it occurred to
me that the biggest difference in operating on children vs. adults is the effects
of time.

We teach our students to learn anatomy and surgery in all
three dimensions. It is not just the
flat shape of a structure that is important, it is also its alignment in space
and its relationship to the structures next to it on all sides. But it seems to me that pediatric specialists
bring a unique perspective to the operating table. We also have to look at things in the fourth
dimension – time.

All structures change with time. Human anatomy and physiology is by no means
immune to the effects of the passing years.
But once adulthood is reached, the changes in the body are less
dramatic. A thirty year old is almost
the same anatomically as her forty year old self, barring disastrous
pathology. The opposite is true with
children. Small increments of even a few
months during the growth spurt can change the length, the breadth and even the
shape of an anatomic structure in a child.

Consequently, when we as pediatric providers make a decision
on treatment, we are not only looking at the child in the clinic on that given
day. We are also calculating the passage
of time, reading the tea leaves and consulting the crystal ball to determine
what that child will be like – with and without treatment – in a month, in six
months, in six years and in sixty years.
Our decision is not only based on the two dimensions of an x-ray or even
the three dimensions of the alignment on the clinical examination. That fourth dimension, the effect of time, is
also of paramount importance.

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